Health Promotion and Maintenance
54. A laboring client, who is gravida 1, para 0, has had no change in her cervix for 2 hours and remains 9 to 10 cm dilated. The fetal head has remained at 0 station. A sterile vaginal examination reveals a position of occiput posterior. Which action by the nurse would be most appropriate?
. Prepare the client for a forceps rotation.
. Assist the client to a hands-and-knees position.
. Assist the client to a supine position.
. Prepare the client for a cesarean delivery.
Test-Taking Tip
This question is asking for the intervention to rotate the fetal head from occipitoposterior to occipitoanterior. Which action assists the fetus to rotate?
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because use of forceps when the client is not completely dilated is not acceptable practice according to the American College of Obstetricians and Gynecologists. Answer 2 is correct because maternal position changes such as sitting, kneeling, lateral, or hands and knees can assist fetal head rotation from an occipitoposterior to an occipitoanterior position. Answer 3 is incorrect because, in the supine position, the gravid uterus compresses the pelvic blood vessels and compromises uteroplacental blood flow. This position not only has no effect on rotation of the fetal head, but can cause decreased perfusion to the placenta. Answer 4 is incorrect because cesarean delivery should be considered only if adequate contractions are documented and there is still no change in the cervical dilation.